HomeMy WebLinkAboutSeptic Pumping Slip - 115 LACONIA CIRCLE 4/23/2014 N
Commonwealth Of Massachusetts
City/Town Of Na Andover C1 0 10 /,,'(J14
System Pumping Record
a
Form 4 y
DEP has provided this form for use by local Boards of Health. Other forms may be used, but the
information must be substantially the same as that provided here. Before using this form, check with your
local Board of Health to determine the form they use. The System Pumping Record must be submitted to
the local Board of Health or other approving authority within 14 days from the pumping date in
accordance with 310 CMR 15.351.
A. Facility Information
Important:When
filling out forms 1. System Location:
on the computer,
use only the tab 115 1 9 (_101) (Gi 1 r
key to move your Address
cursor-do not No Andover
use the return Ma
key. City{Town State
Zip Code
VkA 2. System Owner:
Name
maun
Address(if different from location)
City{Town State
Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping Da e 2. Quantity Pumped:
Gallons
3. Type of system: ❑ Cesspool(s) ffSeptic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes ❑ No If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System: 61
t
§y stem Pumped By:
t.,k It Pr In re
Name
Vehicle License Number
Stewart's Septic Service
Company
7. Location where contents were disposed:
Stewart's Pre-treatment Plant, 20 So. Will Bradford, Ma 01835
i r�a tura�of��e-
�,S Date
Srghature of Receiving {y „
Facili Date
t5form4.doc 03{06 System Pumping Record•Page 1 of 1